Review of integrated mental health and substance abuse treatment for patients with dual disorders

Psychiatric and addiction consultation for patients in critical care

Practicing within the paradigm of compartmentalized specially treatment without a collaborative practice is ineffective for the chemical dependency and dual diagnosis population. Chemical dependency is not well understood as a disease, evidenced by barriers cited from the 2005 Survey on Drug Use and Health. Recovery from addiction and dual diagnosis logically demands an integrated and science-based treatment approach with unified standards for care and improved educational standards for preparation of care providers. Consultation and collaboration with addiction and psychiatric specialists is needed to establish consistency in standards for treatment and holistic care, essential for comorbidity. Continued learning and research about the complexity of the addiction process and comorbidity will provide continued accurate information about the harmful effects of alcoholism and drug abuse which in turn will empower individuals to make informed choices and result in better treatment and social policies.

Pharmacotherapy of alcohol use disorders and concurrent psychiatric disorders: a review

Alcohol use disorders (AUDs) are among the most prevalent psychiatric disorders. Epidemiologic studies have shown a high prevalence of concurrent psychiatric disorders among people with AUDs as well as a higher prevalence of AUDs in people with psychiatric disorders than in the general population. Though psychiatric patients with concurrent AUDs are at increased risk for morbidity and mortality, they are commonly undertreated for their alcohol-related disorders. The efficacy of pharmacotherapy for AUDs is well documented. Our paper reviews the common pharmacotherapies available for AUDs and focuses on the available research regarding treatment of AUDs among psychiatric populations with mood, anxiety, and psychotic disorders. Despite the high prevalence of concurrent AUDs and psychiatric disorders, very limited information has been collected using a randomized controlled trial design targeting those concurrent conditions. Several prevalent psychiatric disorders have not been studied when co-occurring with AUDs. Further research of pharmacological treatments for concurrent AUDs and psychiatric diagnoses is urgently needed.

Intensive intervention for alcohol-dependent smokers in early recovery: a randomized trial

INTRODUCTION

The purpose of this study was to investigate the efficacy of an intensive tobacco cessation intervention for alcohol-dependent smokers in early recovery.

METHODS

A total of 162 alcohol-dependent smokers were randomized to either intensive intervention for smoking cessation or usual care. The intensive intervention consisted of 16 sessions of individual cognitive behavior therapy (CBT) and combination nicotine replacement therapy that lasted 26 weeks. Usual care involved referral to a free-standing smoking cessation program that provided smoking cessation counseling of varying duration and guideline-concordant medications. The primary cessation outcome was verified 7-day point prevalence abstinence (PPA) at 12, 26, 38, and 52 weeks.

RESULTS

At 12 and 26 weeks, the verified 7-day point-prevalence quit rate was significantly higher for the intensive intervention group than for the usual care group (both p=0.03). However, the quit rates for the two treatment groups were not significantly different at 38 or 52 weeks. Verified 30-day alcohol abstinence rates were not significantly different for the two treatment groups at any of the follow-up assessments.

CONCLUSIONS

The intensive smoking cessation intervention yielded a higher short-term smoking quit rate without jeopardizing sobriety. A chronic care model might facilitate maintenance of smoking cessation during the first year of alcohol treatment and perhaps for longer periods of time. It is hoped that studies such as this will inform the development of more effective interventions for concurrent alcohol and tobacco use disorders.

Reasons for substance use among people with mental disorders

BACKGROUND

Comorbidity of mental disorders and substance use continues to be a major problem. To inform the development of more effective interventions for these co-existing disorders, this paper aimed to determine if there are clear variations in the reasons for tobacco, alcohol or cannabis use across people with different mental disorders.

METHODS

Data from five randomized controlled trials on co-existing disorders that measured reasons for tobacco, alcohol or cannabis use using the Drug Use Motives Questionnaire, Reasons for Smoking Questionnaire or via free response are reported and combined. Two studies involved participants with depression, two involved participants with a psychotic disorder and one involved participants with a range of mental disorders. A series of logistic regressions were conducted to examine differences in reasons for tobacco, alcohol or cannabis use and to compare these reasons between people with psychotic disorders or depression.

RESULTS

Participants had a mean age of 38 (SD=12) and just over half (60%) were male. Forty-six percent of participants had a psychotic disorder and 54% experienced depression. Data from 976 participants across the five studies were included in the analyses. Tobacco and alcohol were primarily used to cope, while cannabis was primarily used for pleasure. People with psychotic disorders were more likely than people with depression to use tobacco for coping, pleasure and illness motives. People with depression, in contrast, were more likely to use alcohol for these reasons and social reasons.

CONCLUSIONS

It may be important to tailor interventions for co-existing mental disorders and substance use by substance type and type of mental disorder. For example, interventions might be improved by including alternative coping strategies to tobacco and/or alcohol use, by addressing the social role of alcohol and by helping people with mental disorders using cannabis to gain pleasure from their lives in other ways.

Predictors of participation in community outpatient psychosocial rehabilitation in schizophrenia

This study investigated demographic, clinical and neurocognitive factors predicting drop-out from an intensive, community outpatient psychosocial rehabilitation program for people with schizophrenia or schizoaffective disorder. One-hundred and twenty-seven outpatients with DSM-IV schizophrenia or schizoaffective disorder participated. Demographic variables of age, sex, education and race/ethnicity were recorded and formal symptom measures and a neurocognitive assessment consisting of measures of crystallized verbal ability, sustained visual vigilance, verbal learning, verbal fluency and problem-solving were administered at study entry. Thirty-seven percent of the sample dropped-out of the program. In a final multivariate model, younger age, and lower verbal fluency scores in clients with a history of a high number of hospitalizations predicted a greater likelihood of drop-out. The implications of these findings are discussed.

Integrated Residential Treatment for Persons with Severe and Persistent Mental Illness: Lessons in Recovery

This retrospective study examines 24-month outcomes for 38 participants with histories of chronic homelessness and hospitalizations in an urban, residential integrated treatment (IT) program and compares characteristics of those who stayed in the program 24 months with those who left within their first year of residence. Informed by an Assertive Community Treatment approach, characterized by outreach (or what might better be referred to as inreach), low staff to consumer ratio, and meeting of basic needs, the residential program emphasized harm reduction and motivational interventions. The longitudinal study design was supplemented with a comparative analysis of treatment completers and noncompleters. There were significant differences between the two groups at baseline in terms of engagement with treatment, alcohol use severity, and mental health diagnosis. Additionally, those who stayed with the program showed significant reductions in alcohol and drug use, significant reduction in hospitalizations, and advances in treatment engagement.

Expectancies regarding the interaction between smoking and substance use in alcohol-dependent smokers in early recovery

The purpose of this study was to investigate expectancies regarding the interaction between cigarette smoking and use of alcohol among alcohol-dependent smokers in early recovery, using the Nicotine and Other Substances Interaction Expectancies Questionnaire (NOSIE). Participants were 162 veterans, 97% male, with a mean age of 50 years, enrolled in a clinical trial aimed at determining the efficacy of an intensive smoking cessation intervention versus usual care. At baseline, participants were assessed on measures of smoking behavior, abstinence thoughts about alcohol and tobacco use, symptoms of depression, and smoking-substance use interaction expectancies. In addition, biologically verified abstinence from tobacco and alcohol was assessed at 26 weeks. Participants reported that they expected smoking to have less of an impact on substance use than substance use has on smoking (p < .001). Severity of depressive symptoms was significantly associated with the expectancy that smoking provides a way of coping with the urge to use other substances (p < .01). The expectation that smoking increases substance urges/use was predictive of prospectively measured and biologically verified abstinence from smoking at 26 weeks (p < .03). The results add to our knowledge of smoking-substance use interaction expectancies among alcohol-dependent smokers in early recovery and will inform the development of more effective counseling interventions for concurrent alcohol and tobacco use disorders.

Implementation of an evidence-based modified therapeutic community: staff and resident perspectives

The widespread successful implementation of evidence-based practices (EBPs) into community substance abuse settings require a thorough understanding of practitioner and client attitudes toward these approaches. This paper presents the first that we know of a qualitative study that explores staff and resident experience of the change process of a therapeutic community to an evidence-based modified therapeutic community for homeless individuals with co-occurring substance abuse and mental illness disorders. The sample consists of 20 participants; 10 staff and 10 residents. Interviews were conducted at the agency, recorded and transcribed verbatim. Transcripts were organized and coded from a grounded theory perspective. Themes and patterns of staff and resident experience were identified. The change in program structure from TC to MTC were perceived by staff as efforts to accommodate the particular needs of the homeless individuals with mental and substance abuse disorders and feeling they were inadequately prepared with inadequate resources to facilitate a successful transition. Participant descriptions were described in terms of loss of structure, loss of peers and being helped. Findings have potential to shape implementation of evidence-based practices in community substance abuse treatment.

Dual diagnosis clients' treatment satisfaction - a systematic review

BACKGROUND

The aim of this systematic review is to synthesize existing evidence about treatment satisfaction among clients with substance misuse and mental health co-morbidity (dual diagnoses, DD).

METHODS

We examined satisfaction with treatment received, variations in satisfaction levels by type of treatment intervention and by diagnosis (i.e. DD clients vs. single diagnosis clients), and the influence of factors other than treatment type on satisfaction. Peer-reviewed studies published in English since 1970 were identified by searching electronic databases using pre-defined search strings.

RESULTS

Across the 27 studies that met inclusion criteria, high average satisfaction scores were found. In most studies, integrated DD treatment yielded greater client satisfaction than standard treatment without explicit DD focus. In standard treatment without DD focus, DD clients tended to be less satisfied than single diagnosis clients. Whilst the evidence base on client and treatment variables related to satisfaction is small, it suggested client demographics and symptom severity to be unrelated to treatment satisfaction. However, satisfaction tended to be linked to other treatment process and outcome variables. Findings are limited in that many studies had very small sample sizes, did not use validated satisfaction instruments and may not have controlled for potential confounders. A framework for further research in this important area is discussed.

CONCLUSIONS

High satisfaction levels with current treatment provision, especially among those in integrated treatment, should enhance therapeutic optimism among practitioners dealing with DD clients.

Program planning and staff competencies for forensic assertive community treatment: ACT-eligible versus FACT-eligible consumers

PURPOSE

Forensic assertive community treatment (FACT) is a recent adaptation of the assertive community treatment (ACT) model; however, more information is needed about how FACT and ACT consumers differ and how FACT should be modified to accommodate these differences.

METHOD

Linked, multisystem administrative data from King County, Washington, were used to compare the demographic, clinical, and criminal justice characteristics of ACT- and FACT-eligible consumers.

RESULTS

FACT consumers were more likely to be male, persons of color, and had more complex clinical profiles. Also, some FACT consumers were incarcerated for sex offenses, and more than half had violent offenses.

CONCLUSIONS

Traditionally, ACT teams avoid serving consumers with personality disorders, violent consumers, and sex offenders; however, given increased use of mandated outpatient treatment and mental health courts, FACT teams may have less discretion to choose whom they serve. The addition of clinical interventions and other modifications may be particularly important for FACT teams.

Treatment outcomes of an integrated residential programme for patients with schizophrenia and substance use disorder

BACKGROUND

About half of all schizophrenic patients have a co-occurring substance use disorder, leading to poorer social and functional outcomes than obtained in non-abusing patients. To improve outcomes, integrated treatments have been designed that address the two conditions simultaneously. Results are, however, conflicting because the available effect studies are hampered by various methodological issues, among which are heterogeneous patient samples.

METHODS

In this comparative study, two well-described patient samples diagnosed with schizophrenia and co-morbid substance abuse disorders either received an integrated treatment (IDDT) or treatment as usual (TAU).

RESULTS

Patients in the IDDT condition showed significant reductions in illicit drug and alcohol use, improvements on all psychiatric symptom domains, reported higher quality of life and improved on social and community functioning. In contrast, patients' improvements in the TAU group were moderate and limited to a few substance use and psychiatric outcomes. The TAU group had significantly higher dropout rates 6 and 12 months after baseline, suggesting that the IDDT programme was more successful in committing patients.

CONCLUSIONS

Our results suggest that an integrated approach to schizophrenic patients and co-morbid substance use disorders is superior to standard treatment and may be considered as the treatment of choice for this patient group.

Fidelity of implementation: development and testing of a measure

BACKGROUND

Along with the increasing prevalence of chronic illness has been an increase in interventions, such as nurse case management programs, to improve outcomes for patients with chronic illness. Evidence supports the effectiveness of such interventions in reducing patient morbidity, mortality, and resource utilization, but other studies have produced equivocal results. Often, little is known about how implementation of an intervention actually occurs in clinical practice. While studies often assume that interventions are used in clinical practice exactly as originally designed, this may not be the case. Thus, fidelity of an intervention's implementation reflects how an intervention is, or is not, used in clinical practice and is an important factor in understanding intervention effectiveness and in replicating the intervention in dissemination efforts. The purpose of this paper is to contribute to the understanding of implementation science by (a) proposing a methodology for measuring fidelity of implementation (FOI) and (b) testing the measure by examining the association between FOI and intervention effectiveness.

METHODS

We define and measure FOI based on organizational members' level of commitment to using the distinct components that make up an intervention as they were designed. Semistructured interviews were conducted among 18 organizational members in four medical centers, and the interviews were analyzed qualitatively to assess three dimensions of commitment to use--satisfaction, consistency, and quality--and to develop an overall rating of FOI. Mixed methods were used to explore the association between FOI and intervention effectiveness (inpatient resource utilization and mortality).

RESULTS

Predictive validity of the FOI measure was supported based on the statistical significance of FOI as a predictor of intervention effectiveness. The strongest relationship between FOI and intervention effectiveness was found when an alternative measure of FOI was utilized based on individual intervention components that had the greatest variation across medical centers.

CONCLUSIONS

In addition to contextual factors, implementation research needs to consider FOI as an important factor in influencing intervention effectiveness. Our proposed methodology offers a systematic means for understanding organizational members' use of distinct intervention components, assessing the reasons for variation in use across components and organizations, and evaluating the impact of FOI on intervention effectiveness.

Barriers to comorbidity service delivery: the complexities of dual diagnosis and the need to agree on terminology and conceptual frameworks

This paper draws from a literature review commissioned as part of a larger project evaluating comorbidity treatment service models, which was funded by the Australian Government Department of Health and Ageing as part of the National Comorbidity Initiative. The co-occurrence of mental health and substance use disorders (comorbidity) is a common and complex problem. This paper outlines conceptual and practical complexities and barriers associated with comorbidity treatment service delivery, particularly around the variable nature of comorbidity, and the impacts of the separation of the mental health (MH) and alcohol and other drug (AOD) sectors with their differing institutional cultures, aetiological concepts, philosophical underpinnings, educational requirements, administrative arrangements, and screening and treatment approaches. Issues pertaining to the lack of consistent definitions and conceptual frameworks for comorbidity are discussed, particularly in relation to the reported lack of communication, collaboration, and linkages between the sectors. It is suggested that the adoption of consistent terminology and conceptual frameworks may provide a valuable step towards consistency in service provision and research and could lead to improved capacity to address the many issues relating to comorbidity service provision and treatment efficacy.

Housing Preferences among Adults with Dual Diagnoses in Different Stages of Treatment and Housing Types

Housing is an essential component of psychiatric rehabilitation, particularly for consumers with dual diagnoses. Research has not clearly examined why and when consumers prefer different types of housing. This exploratory study examined 1) whether housing preferences differ between stage of treatment for substance abuse, 2) whether consumers who prefer certain housing types have preferences for certain characteristics, and 3) whether consumers living in different types of housing report differences in social support, choice, and housing satisfaction. A total of 103 participants living in supervised housing (n= 65), independent apartment housing (n= 22), single room occupancy hotels (n= 11), and with family (n= 5) completed self-report questionnaires. Results showed that 1) the majority of participants preferred their own apartment or house across different stages of treatment, 2) preference for supervised housing was associated with on-site staff and peer support while preference for apartment housing was associated with autonomy and privacy, and 3) consumers in single room occupancies reported the least choice and lowest satisfaction. These findings contribute to the understanding of consumers' housing preferences and the differences consumers perceive between certain housing types.

Treating comorbid substance use disorders in schizophrenia

AIM

To review the literature on pharmacological and psychosocial treatment approaches for people with schizophrenia and comorbid substance use disorder(s) (SUD).

METHOD

Selective literature review.

RESULTS

Despite the high prevalence of comorbid SUD among people with schizophrenia, there is a considerable paucity of rigorously conducted randomized controlled treatment trials. While there is some evidence for clozapine, and for the adjunctive use of agents such as naltrexone for comorbid alcohol dependence, the available literature largely comprises case studies, case series, open label studies and retrospective surveys. In terms of psychosocial approaches, there is reasonable consensus that integrated approaches are most appropriate. Regarding specific aspects of care, motivational interviewing, cognitive behavioural therapy and contingency management have an emerging supportive literature, as do family interventions. However, there is no 'one size fits all', and a flexible approach with the ability to apply specific components of care to particular individuals, is required. Group-based therapies and longer-term residential services have an important role for some patients, but further research is required to delineate more clearly which patients will benefit from these strategies.

CONCLUSIONS

While there is growing (albeit limited) evidence that integrated and well articulated interventions that encompass pharmacological and psychosocial parameters can be beneficial for people with schizophrenia and comorbid SUD, there remains a considerable gap in the literature available to inform evidence-based practice.

Management of the adolescent with substance use disorders and comorbid psychopathology

Substance use disorders are common in youth, and co-occurring psychiatric disorders are present in the majority of cases. This article reviews clinical considerations unique to the population, including intricacies of assessment and special treatment considerations. Several psychotherapeutic intervention models are discussed, including cognitive-behavioral therapy, dialectic behavior therapy, motivational enhancement therapy/motivational interviewing, family behavior therapy, multidimensional family therapy, and multisystemic therapy. Research on psychopharmacologic treatment is limited, and primarily focuses on mood disorders and attention deficit/hyperactivity disorder. To maximize outcome, recommendations based on practice parameters promote integration of treatment modalities versus serial or concurrent treatment of co-occurring substance use and psychiatric disorders.

Treatment guidelines for substance use disorders and serious mental illnesses: do they address co-occurring disorders?

Practice guidelines are important tools for improving the delivery of evidence-based practices and reducing inappropriate variation in current treatment approaches. This study examined the degree to which guidelines targeted to the treatment of substance use disorders or serious mental illness address treatment of co-occurring disorders. Guidelines archived by the National Guideline Clearinghouse (NGC) were retrieved in December 2007 and content analyzed. Nineteen pertinent guidelines were identified, and 11 included recommendations regarding the assessment and/or treatment of co-occurring disorders. None of the guidelines making recommendations for treatment of co-occurring disorders included outcomes that clearly targeted both substance use and mental health disorders. Limitations and implications of this study are noted.

Treatment seeking adults with autism or ADHD and co-morbid substance use disorder: prevalence, risk factors and functional disability

BACKGROUND

Little is known about Autism Spectrum Disorder (ASD) in adults, especially not about ASD with co-morbid Substance Use Disorder (SUD). We wanted to examine how adults with ASD compare to adults with ADHD on prevalence and risk factors for co-morbid SUD, and on disability levels associated with SUD.

METHODS

We stratified 123 treatment seeking adults with ASD (n=70) or ADHD (n=53), into current, former and no history of SUD (SUD+, SUD(wedge), and SUD-), and conducted interviews to explore associated risk factors and current levels of disability.

RESULTS

Prevalence of co-morbid SUD was higher in ADHD than in ASD in our sample (58% versus 30%, p=0.001). There was no statistically significant difference between ASD and ADHD in risk factors or disability scores. Patients with lifetime SUD started regular smoking earlier in life (OR=5.69, C(95%) 2.3-13.8), reported more adverse family events (OR=2.68; CI(95%) 1.2-6.1), and had more parental SUD (OR=5.36; CI(95%) 1.0-14.5). Disability scores were significantly lower in SUD- and SUD(wedge) groups compared to the SUD+ group.

DISCUSSION

These findings suggest that ASD and ADHD share similar risk factors for SUD. High disability in ASD and ADHD with SUD may normalize after prolonged abstinence. Early onset of SUD was not associated with more severe disability scores than later onset. Results suggest that a subgroup of patients with former SUD may have a higher level of functioning before the onset of SUD in comparison to those without lifetime SUD.

Is implementation of the 5 A's of smoking cessation at community mental health centers effective for reduction of smoking by patients with serious mental illness?

We tested whether implementing the "5 A's" (Ask, Advise, Assess, Assist, Arrange) at six mental health centers reduces smoking among persons with serious mental illness. One hundred and fifty six patients were evaluated just before initiating the 5 A's and after six and 12 months. A delayed control condition evaluated 148 patients six months before 5 A's implementation, just before and then after six months. Six months of the 5 A's produced no effect. Modest cessation and reduction benefits were noted after 12 months. Implementing the 5 A's at community mental health centers may have modest benefit after twelve months.

Examining factorial structure and measurement invariance of the Brief Symptom Inventory (BSI)-18 among drug users

The purpose of this study is to examine the factorial structure of the Brief Symptom Inventory 18 (BSI-18) and test its measurement invariance among different drug using populations. A total sample of 710 drug users was recruited using respondent-drive sampling (RDS) from three states: Ohio (n=248), Arkansas (n=237), and Kentucky (n=225). The results of confirmatory factor analysis (CFA) show: 1) the BSI-18 has a three-factor structure (somatization, depression, and anxiety) with an underlying second-order factor (global severity index of distress); and 2) its factorial structure and metric (factor loadings) are invariant across populations under study. However, the scalars (intercepts) of the BSI-18 items are not invariant, and the means of the latent factors also varied across populations. Our findings provide evidence of a valid factorial structure of the BSI-18 that can be readily applied to studying drug using populations.

Dual diagnosis in a Dublin tertiary addiction centre - A cross-sectional study

OBJECTIVES

To address the relative dearth of information relating to the prevalence of psychiatric co-morbidity among attenders of community addiction facilities.

METHODS

We carried out a cross-sectional study of clients attending a Dublin-based tertiary addiction centre to assess the rates of psychiatric co-morbidity, determine the demographic and clinical variables and evaluate the level of contact with allied medical care especially primary care and community psychiatric services. Information was sourced from available patient records.

RESULTS

Forty-three per cent of the clients (n = 59), attending the service were found to have a chart diagnosis of psychiatric disorder. Only 15% of these were in contact with community psychiatric services.

CONCLUSIONS

This high rate of psychiatric co-morbidity has implications in terms of funding, training and service delivery.

Changes in treatment content of services during trauma-informed integrated services for women with co-occurring disorders

The experience of trauma is highly prevalent in the lives of women with mental health and substance abuse problems. We examined how an intervention targeted to provide trauma-informed integrated services in the treatment of co-occurring disorders has changed the content of services reported by clients. We found that the intervention led to an increased provision of integrated services as well as services addressing each content area: trauma, mental health and substance abuse. There was no increase in service quantity from the intervention. Incorporation of trauma-specific element in the treatment of mental health and substance abuse may have been successfully implemented at the service level thereby better serve women with complex behavioral health histories.

Reprint of "Treatment of cannabis use disorders in people with schizophrenia spectrum disorders--a systematic review"

BACKGROUND

Cannabis use disorders (CUD) are prevalent among people with schizophrenia spectrum disorders (SSD), with a range of detrimental effects, e.g. reduced compliance to medication and psychosocial interventions, and increased level of psychotic-dimension symptoms. The aim of this study was to review literature on treatments of CUD in SSD-patients.

METHODS

PubMed, PsycINFO, EMBASE, and The Cochrane Central Register of Controlled Trials were searched.

RESULTS

41 articles were selected, 11 treating cannabis as a separate outcome. Contingency management was only effective while active. Pharmacological interventions appeared effective, but lacked randomized controlled trials (RCTs). Psychosocial interventions, e.g. motivational interviewing and cognitive behavior therapy (CBT), were ineffective in most studies with cannabis as a separate outcome, but effective in studies that grouped cannabis together with other substance use disorders.

CONCLUSIONS

Insufficient evidence exists on treating this form of dual-diagnosis patients. Studies grouping several types of substances as a single outcome may overlook differential effects. Future RCTs should investigate combinations of psychosocial, pharmacological, and contingency management.

Client and service characteristics associated with addiction treatment completion of clients with co-occurring disorders

The study examines client and service characteristics of addiction treatment completers and non-completers with co-occurring disorders (COD). On demographic variables, completers were more likely to be male and homeless. In the psychiatric domain, a greater proportion of completers received diagnoses of depression and generalized anxiety disorder, whereas non-completers were more often diagnosed with bipolar disorder and posttraumatic stress disorder. No group differences were found in client-reported psychiatric symptom severity; however, non-completers were rated by clinicians as having more severe symptoms in the areas of interpersonal sensitivity, depression, and hostility. In the area of substance use patterns, no differences were found in primary substance of abuse but completers reported more days of use during the month prior to treatment. Completers also had a greater history of both prior detox and non-detox treatment. At discharge, completers achieved higher rates of past month abstinence and AA attendance, but no differences were found in length of stay in treatment. Examination of recovery support services utilization revealed that completers more often received peer mentoring services. Greater proportions of the non-completer group received educational support, clothing, medical care, and employment assistance. These results suggest that future studies are needed in examining possible differential treatment response by diagnostic category and the potential role of peer mentoring in enhancing addiction treatment completion of COD clients.

Assessing the Service Linkages of Substance Abuse Agencies with Mental Health and Primary Care Organizations

Fragmentation of substance abuse treatment represents a major barrier to effective treatment for individuals with cooccurring substance abuse and mental and physical health disorders. Linkages of substance abuse treatment organizations with primary care and mental health agencies are widely considered to be a feasible way to integrate services. In this study, we analyzed information collected from a national sample of 62 outpatient substance abuse treatment units (OSATs) to understand the extent of services linkages in these organizations and to identify facilitators and barriers to service linkages. Results showed that OSATs had limited service linkages with primary care and mental health providers. The cited barriers to linkages included clients' financial problems, managed care restrictions, and limited organizational capacity. Onsite service provision was implemented in some OSATs. The pattern of service linkages in OSATs appeared to reflect the health needs of substance abuse clients.

Psychometric properties of the dual-disorder treatment fidelity scale: inter-rater reliability and concurrent validity

Psychometric properties of the Dual-Disorder Treatment Fidelity Scale (Mueser et al. Integrated treatment for dual disorders: A guide to effective practice, 2003) were evaluated. Reliability was assessed through measures of inter-rater agreement, and validity was assessed through a concurrent known groups validation procedure. Two raters assessed three community mental health center (CMHC) and three specialized dual diagnosis (DDE) programs for fidelity; inter-rater agreement was good. Total fidelity scores did not distinguish between CMHC and DDE program types; however, a cluster analysis revealed concurrent validity based on the item level ratings. Conclusions drawn from item level ratings appear valid; the validity of conclusions based on total scores remains unsupported.

Treatment of cannabis use disorders in people with schizophrenia spectrum disorders - a systematic review

BACKGROUND

Cannabis use disorders (CUD) are prevalent among people with schizophrenia spectrum disorders (SSD), with a range of detrimental effects, e.g. reduced compliance to medication and psychosocial interventions, and increased level of psychotic-dimension symptoms. The aim of this study was to review literature on treatments of CUD in SSD-patients.

METHODS

PubMed, PsycINFO, EMBASE, and The Cochrane Central Register of Controlled Trials were searched.

RESULTS

41 articles were selected, 11 treating cannabis as a separate outcome. Contingency management was only effective while active. Pharmacological interventions appeared effective, but lacked randomized controlled trials (RCTs). Psychosocial interventions, e.g. motivational interviewing and cognitive behavior therapy (CBT), were ineffective in most studies with cannabis as a separate outcome, but effective in studies that grouped cannabis together with other substance use disorders.

CONCLUSIONS

Insufficient evidence exists on treating this form of dual-diagnosis patients. Studies grouping several types of substances as a single outcome may overlook differential effects. Future RCTs should investigate combinations of psychosocial, pharmacological, and contingency management.

Models of co-occurring substance misuse and psychosis: are personality traits the missing link?

Traditional models of co-occurring substance misuse in psychosis, including the vulnerability and coping (self-medication) hypotheses, have tended to focus on state-specific factors, such as the severity of substance misuse or psychotic symptoms. In contrast, more recent personality models posit that co-morbidity is related to individual differences in stable trait-specific personality variables that underlie affective outcomes, coping strategies and subsequent risk for substance use. This paper reviews the current evidence base for these three models, and suggests that future research examine the inter-relationships between trait and state-specific personality, affective and behavioural variables on co-morbidity.

A brief motivational intervention for substance misuse in recent-onset psychosis

Substance misuse is common in early psychosis, and impacts negatively on outcomes. Little is known about effective interventions for this population. We report a pilot study of brief intervention for substance misuse in early psychosis (Start Over and Survive: SOS), comparing it with Standard Care (SC). Twenty-five in-patients aged 18-35 years with early psychosis and current misuse of non-opioid drugs were allocated randomly to conditions. Substance use and related problems were assessed at baseline, 6 weeks and 3, 6 and 12 months. Final assessments were blind to condition. All 13 SOS participants who proceeded to motivational interviewing reported less substance use at 6 months, compared with 58% (7/12) in SC alone. Effects were well maintained to 12 months. However, more SOS participants lived with a relative or partner, and this also was associated with better outcomes. Engagement remained challenging: 39% (16/41) declined participation and 38% (5/13) in SOS only received rapport building. Further research will increase sample size, and address both engagement and potential confounds.

A tale of two systems: co-occurring mental health and substance abuse disorders treatment for adolescents

Co-occurring disorders present serious challenges to traditional mental health and substance abuse treatment systems. Among adolescents in need of behavioral health services, co-occurring disorders are highly prevalent and difficult to treat. Without effective intervention, youth with co-occurring disorders are at increased risk of serious medical and legal problems, incarceration, suicide, school difficulties and dropout, unemployment, and poor interpersonal relationships. In general, current service systems are inadequately prepared to meet this need due to a variety of clinical, administrative, financial, and policy barriers. This article presents an overview of co-occurring disorders among adolescents, highlights general considerations for co-occurring disorders treatment, reviews selected treatment models and outcomes, and discusses recommendations and best practice strategies.

Criminality and Addiction: Selected Issues for Future Policies, Practice, & Research

The high cost of incarceration and a general confidence in the effectiveness of drug abuse treatment have led many states to adopt community-based drug abuse treatment as part of, or as an alternative to, incarceration. Community re-entry and aftercare have therefore received increasing attention from both practitioners and researchers. This article examines possibilities for encouraging change in both adult and juvenile justice treatment. Four issues are highlighted: (1) relapse and aftercare, (2) co-occurring disorder, (3) juvenile justice programming, and (4) women's treatment. The success of U.S. drug treatment policy depends on a capacity to resolve these and related issues.